Introducing Social Change through Community Health

by W. Meredith Long

By intelligently transcending cultural barriers rather than being shut out by them, Christian health care workers can introduce basic changes in non-Christian belief systems and practices.

By intelligently transcending cultural barriers rather than being shut out by them, Christian health care workers can introduce basic changes in non-Christian belief systems and practices. Dr. Rajanikant Arole and his wife, Dr. Mabelle Arole, returned from the United States to their home country of India because they felt God’s call to ministry. They established a health project in a poor rural area of Maharashtra state. Together they set out not only to improve the health of the surrounding people but to transform their world view with the light of God. Here is part of their story.

THE COMPREHENSIVE RURAL HEALTH PROJECT: JAMKHED
The Comprehensive Rural Health Project of Jamkhed, Maharashtra state, encompassing 100,000 people in 70 villages of this small corner of rural India, has successfully addressed most of the health problems commonly facing rural villages in the developing world. In the first 12 years of the project, infant mortality dropped from 150 to about 30 per thousand, and the proportion of malnourished children decreased from 30 percent to 5 percent. Additionally, 500 hectares of land were reclaimed and placed into cultivation, the people commonly practice good sanitation and hygiene, and villagers have cooperated to build houses for the landless.¹ There is now so little malnutrition and infectious disease that the village health workers are turning their attention to the problems of aging and chronic diseases.²

Mabelle Arole, however, speaks far more enthusiastically about the changes in basic cultural values among the villagers. The biblical values that motivated and shaped the Aroles’ work contrasted at many points with the values of the predominant Indian culture. They prayerfully and successfully challenged many of those values and began to see them change.

I interviewed Mabelle Arole and Muktabai, one of the village health workers, when they addressed the National Council of International Health’s annual conference in Washington, D.C. in May, 1988. I focused the interview on how the Aroles introduced their Christian values first into the culture of the project and subsequently into the wider community.

VALUES OF THE PROJECT
The values which guided the Aroles in the development of the Jamkhed project were explicitly Christian.

1. Value and regard for persons as God’s image-bearers. Central to their attitude toward the people with whom they worked was their deeply felt regard for their worth and potential. “Every human being is made in the image of God, and therefore deserves to be treated…with human dignity. An attitude of love, therefore, is central.” says Mabelle Arole.³ A belief in the basic dignity of all humans is the base on which all other relational values are framed.

2. Trusting relationships. Belief in human worth leads to a desire to build trusting relationships. “We put our trust in people, whoever they may be, and work with them in whatever they do. This is the basic principle on which we have always worked. The potential in the human being is great.”⁴ This trust produces an organizational commitment to participative decision making.

3. Power of the poor to implement change. Specifically, the Aroles trusted as their ministry partners many who because of low social status were not ordinarily trusted in Indian society:

Jesus Christ chose his disciples not from the elite and the educated people of his time, but from the poor. If Jesus could entrust his precious message to people who were poor, who were not leaders of his time, then I think we also should realize the potential that there is in people who are less fortunate than we are. We therefore use local people who are not educated, not literate, to carry out our health work.⁵

The Aroles embraced in practice an essential Christian paradox—that God empowers the powerless and builds his kingdom from the poor and humble.

CONFLICTING VALUES FROM INDIAN CULTURE
Because the Aroles had once lived within the culture of the people with whom they now served, they knew notonly of their strengths but also of the cultural values that were hostile to those of God’s kingdom. They also knew that these values would need to be challenged and transformed, if ministry to individuals and communities were to be helpful.

1. The caste system. Although discrimination based upon caste is illegal in India, villages are still deeply fractured between castes, between rich and poor, and between men and women:

In my village the people who have money see to it that the poor don’t get anything. There is also the question of caste. Some are Harijans. They are untouchables. Others say, “I am a Marati. I am of the landed community,” or “I am a Brahmin. I am superior.” The rich children have plenty to eat, but at no time do they even feel for their neighbors who are poor. Instead, they make fun of children who do not have food to eat. They do not have any love in their hearts.⁶

Nor is there in India any cultural reason for having love. A person’s value is not based on any innate qualities of humanity but rather on the caste into which he or she was born. Harijans are being punished for sins of a past life. Since fate is fate, and fate is deserved, the higher born feel little moral obligation to care for the lesser born. Derision is a logical, not a callous, response.

Furthermore, because it is the duty of the lower castes to serve those who are higher, the person who serves is of lesser worth. There is no dignity in physical labor or in humble tasks. Young men of higher castes signal their status by a long fingernail on their little finger, demonstrating to the world that they do not have to labor for their living.

If not challenged, the practices springing from these values would have endangered not only the work of the Jamkhed project but also the development of solidarity among staff members of different caste and economic groups.

2. Mutual suspicion. If humans have no intrinsic value, there is neither the need nor the potential to develop trusting relationships. Mutual suspicion overwhelms mutual trust, expectations of treachery become self-fulfilling, and the cycle continues. A Bengali colleague once told me a story to show the prevalence of suspicion in rural Indian communities:

A jin (or genie) once appeared to a poor farmer and told him that he could have anything he wished for. Excited beyond measure, the farmer almost voiced his wish for land and riches, but the jin interrupted. “Anything that you wish for will be given doubly to your neighbor.”

The farmer was stunned and subdued. He asked the jin to give him time to think and to return the next day. The jin agreed. The next day the spirit asked the farmer if he had decided upon his wish. “Yes, I have,” replied the farmer. “Put out my left eye.”

Relative advantage was more important to this farmer than were his possessions, because he feared that a more powerful neighbor would eventually take what he had. With such endemic distrust, there is little sense of community in Indian villages.

3. Power belongs to the powerful. While families make significant decisions only after long discussion, India provides few if any indigenous models of shared power among people of unequal castes and economic status. Unless it is politically expedient, people of high caste do not invite those of low caste to participate in significant community decisions.

CHALLENGING AND CHANGING BASIC CULTURAL VALUES
In spite of these conflicting values, the Aroles nurtured an organizational culture based upon shared values of human worth, dignity, and service, and characterized by trust and intimacy. The predominate values of their own organization also took root in the villages and brought about a basic level of social change that transcended mere improvements in health.

The Aroles challenged these values in a deliberate and carefully designed strategy. As respected leaders, they modeled these values themselves, they infused the values into project implementation, and they taught the values to the village health workers.

1.The Aroles modeled their values. Muktabai attributed the unique character of the Aroles’ work to their underlying values—values that can be shared and expressed to others:

The Aroles have a deep love for the village people. Because of that,
they have come to us. Real peace is in service to others. Real service
is lifting the poor and downtrodden. The Aroles do not feel, “I am a
big person. I am a big doctor. I want money.” Giving up everything,
they came to us. Because they have the right thoughts and the right
mind, they gave us help and healing. Everything has changed.⁷

Mabelle Arole consciously modeled project values in her relationships with the village health workers, so that they could reproduce those values in their own relationships:

Why is the health worker effective? Because she is showing love to her neighbors. And where did she get that love? She got it from the project. She has experienced love.⁸

2. The Aroles reflected their values in the project strategy. Since the caste system was antithetical to the values of the project, the Aroles directly confronted it among the project workers and villagers. During training, Mabelle Arole asked all the health workers (all of them women) to sleep under one blanket and eat from the same pot of food:

Hunger and cold were our friends, gently persuading the higher caste to eat and sleep with the lower caste women, who were already becoming friends and colleagues. We also took them to the x-ray rooms and showed them that all women from every caste have the same type heart, lungs, and bodies.

In the nutrition program we asked all the children from all the caste groups to bring a glass of water and put it into the cooking pot. The water in the pot was “polluted” by different caste groups. The food was given to all the caste children. The higher caste children’s parents objected to their children eating this polluted food, but their children were hungry and had come to eat. As time went on, the parents got fed up and stopped spanking the children when they came to eat.⁹

Weakening of the caste system was the first but necessary step in the Aroles’ long-term strategy of partnership with the village health workers in management and decision making. As the village health workers grew in their capacity for independent action, and as mutual trust and intimacy increased, the Aroles’ relationship to them also changed:

Over time, the women began to discover and appreciate their own potential and abilities. They began income-generating activities. Their feeling of liberation grew. They knew they could accomplish things important to them. The women are holding hands with us as equal partners….They have taken over the responsibility of primary health care.¹⁰

The degree to which many of the workers embraced the values underlying the project’s organizational culture was reflected in their attitudes toward payment for their services. “Some women are paid. Some refuse to be paid by the women of the community because the women are also poor.”¹¹

3. The Aroles explicitly taught Christian values. The Aroles constantly reinforced Christian values, in the initial training period as well as in their subsequent monthly meetings with village health workers. For the workers, those meetings were the high point of the month, as they gave individual reports and received continuing health and medical education. For the Aroles and the project staff, the meetings were opportunities not only to conduct training but also to build group and individual solidarity around project values.

To teach project values, the Aroles used an inductive process, inviting the women to reflect upon their own lives and those of their neighbors:

We talk about values. What are the values we keep? How do we look at another person? Are we sensitive to another person’s need? Is it right to be sensitive to another person’s need? Is it right…to oppress others? We discuss the attitudes of people in the village. What is the attitude toward women? How are womentreated? Are they treated as human beings? What is caste? Is it just? Why should someone be oppressed, downtrodden, not treated as a human being?¹²

LIMINALITY AND COMUNITAS
Moving from this specific case study to a principle that can be applied generally across cultures, Arnold Van Gennep and Victor Turner discuss the stages in rites of passage in various cultures:

In the first step, separation, the initiates are removed, ritually and often physically, from the social roles and values that form the predominant culture. In the second step, liminality, the initiates hover at the threshold of significant change—freed for a time from the constraints and responsibilities of their old social roles but without the constraints and responsibilities of the new. The final stage is reaggregation, when the initiates return to the dominant, structured society in their new roles, where their new rights and responsibilities are once more defined. Turner suggests that the second, liminal state of a rite of passage is characterized by “communitas,” or, simply, “a community . . . of equal individuals who submit together to the authority of the ritual elders.”¹³

In their initial training of the village health workers the Aroles, accepted by all the workers as “ritual elders” because of their character and status, placed these women into a situation resembling the second, liminal stage of the rite of passage these scholars describe. Eating from the same pot and sleeping under the same blanket marked a ritual separation from the rigid structures of caste and permitted the women to experience communitas. The Aroles placed great emphasis upon the continued training of the village health workers. Not only did the monthly weekend meetings provide opportunities for training; perhaps more importantly, they provided a liminal setting in which relationships could be strengthened and new insights gained—an ongoing renewal of community.

Over the years, the interaction of the village health workers and Aroles began to have an effect that Turner might not have anticipated. During the stage of reaggregation, the initiate returns to society in a new social role, but the society itself does not change. Transformed by their experience of Christ’s love expressed in community, the village health workers returned not just in new roles, but as agents of transformation. Through their ministry, the biblical values of community began slowly to change the predominant society. In many villages the caste system began to crumble and relationships of mutual assistance and trust began to grow. The wells and public facilities were opened to people of lower and higher castes. The higher castes began to feel a responsibility for the welfare of the lower castes. With each step, entire communities moved closer to the kingdom of God as they realized that Jesus’ presence changed lives and cultures. While their understanding of the gospel remained colored by Hinduism, some villages began to worship Jesus.

HEALTH INTERVENTIONS WITHOUT CULTURAL CHANGE: A FAILURE
The intimate linkage between project success and Christian values became apparent when the government of India adopted the Jamkhed model as a national strategy. Dr. Mabelle Arole describes what happened:

The government of India modeled a major component of its community-based health program on the work at Jamkhed. Their program calls for village health workers and women’s clubs. As in Jamkhed, secondary care is to be delivered by a cadre of nurses, with referral into the primary health care center, equivalent to our central hospital. If you look at the government system in terms of management, or as a model, it looks exactly the same as Jamkhed. But somewhere along the line the government loses sight of the fact that they are working with people, not models.

Where the breakdown occurs in the government system is in the answer to the question, “How do the professional staff treat the village health workers?” To them, she is a woman, she is illiterate, and therefore sheis nothing. She is there to be trampled upon. She is their servant. Whatever comes down from on top is heaped on her. “You must do that, you must do that, you must do that.” “You didn’t do this, you didn’t do that.” She is treated as trash.¹⁴

The Aroles looked through the window of health intervention into the world view of the people they served. They looked beyond the reflection of themselves and their medical training, into the hearts of the health workers and villagers. By directing the light of Christ into the dark corners of the people’s world view, the Aroles accomplished far more than decreased rates of mortality and morbidity:

• Their health training revealed that high caste and low caste alike were created by God.
• Their graceful acceptance of the village health workers, along with biblical teaching, ascribed worth and dignity to those who felt worthlessness; and it transformed the basis for worth among those who had been proud.
• Corporate reflection on the causes of poor health revealed the injustice of caste.
• The building of community among the village health workers spilled over into basic social change.

The work of the Aroles challenges evangelicals to reevaluate their health and healing ministries. The Aroles’s health ministry did not simply earn them the opportunity to proclaim the gospel. It was not a physical means to a spiritual end. The Aroles modeled the loving compassion of Christ in their ministry, but their interventions transcended even the witness of their presence. They wove essential messages of the gospel into the fabric of their ministry, challenged the underlying cultural values that obscured the message of the gospel, and brought not only individuals but entire communities closer to God’s kingdom.

Endnotes
1. Chakravorty, Ujjayant N., “A Health Project That Works—Progress in Jamkhed,” World Health Forum, Vol. 4, 198 3, 38-41.
2. Arole, Mabelle, interview with W.M. Long, Washington, D.C., May, 1988
3. Arole interview.
4. Arole interview.
5. Arole interview.
6. Muktabai, interview with W.M. Long, translated to English by M. Arole, Washington, D.C., May, 1988.
7. Muktabai interview.
8. Muktabai interview.
9. Arole interview.
10. Arole interview.
11. Arole interview.
12. Arole interview.
13. Turner, Victor W., The Ritual Process: Structure and Anti-Structure (Chicago: Aldine, 1969), 96.
14. Arole interview.

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